370 Injury: International Journal of the Care of the Injured Vol. 27, No. 5, 1996

ment of patients with major injuries along the lines of the ATLS teaching had lead to improved survival of the seriously injured in Leeds.

S. D. Deo, J. D. Knottenbelt (Cape Town, Republic of South Africa) The use of midazolam in trauma resuscitation

This is the first paper describing the use of midazolam as an adjunct in the initial phase of resuscitation after injury. It is a retrospective study of the use of midazolam in resuscitations after injury over a 6-week period in 1994. In this period 45 patients required endotracheal intubation as part of resuscitation, of whom 33 (73 per cent) were given midazolam. The indications for its use, dose given, and physiological and side effects were noted.

Midazolam was found to be a very safe and viable alternative to muscle relaxants and other anaesthetic agents in injuries allowing endotracheal intubation, as well as other invasive procedures to be carried out with minimal distress to the patient. Sixty-four per cent of patients had a low Glasgow Coma Score and required intubation for airway control and oxygenation. Adjuvant analgesia was required in less than 40 per cent of patients, amnesic properties were excellent and there were no significant physiological or other side effects.

The use of midazolam is recommended in the appropriate environment and its use in the pre-hospital setting should be given consideration.

M. J. Clancy, J. Alderman, C. Case, K. J. W. Taylor (Bristol, UK) The use of ultrasound in the non-invasive defection of changes in the renal circulation in response to blood loss using an animal model

Using a continuous haemorrhage model, eight anaesthetized swine were bled I ml/kg/min for 30 min. The resistance index (RI) of the main renal artery, interlobar and arcuate vessels all significantly increased. Cortical Doppler signals were lost in four animals at a mean arterial pressure of 26 mmHg. After reinfusion of blood and normal saline only the RI of the interlobar vessels was significantly different from baseline readings. Ultrasound non-invasively demonstrated changes in regional blood flow within the kidney in response to hypovolaemic shock.

T. Wardle, P. Driscoll, C. Oxbey, C. Dryer, F. Campbell, M. Woodford, F. Munsal (Chester, UK, and Salford, UK) The

effect of pre-existing medical conditions on the outcome of injured

trauma patients

In a recent retrospective study we have shown that pre-morbid medical conditions (PMC) were present in 39 per cent of UK injured patients with complete records. In view of the incidence of incomplete documentation, it could be argued that this figure was artificially high. The aim of this study therefore was to carry out a detailed investigation in one UK centre to ascertain the incidence of PMC and determine its effect on patient outcome.

Injured patients from Hope hospital included in the Major Trauma Outcome Study between 1988-1990 were investigated. All deaths from injuries (N= 121) and a random sample of survivors (N= 1350) were analysed for PMC (i.e. cardiovascular, respiratory, metabolic, neurological, and others), Injury Severity Score (ISS), Revised Trauma Score (RTS), age and outcome.

PMC were found in all age groups but their occurrence increased directly with age (Mantel-Haenszel 1’ P= 0.0001).

The most common PMC was cardiovascular disease which was found in 14.8 per cent of all patients and 19 per cent of those who died. Six hundred and sixty-four patients (45 per cent) had one or more PMCs. This group had a percentage mortality of 10.7 per cent which compared with 6.2 per cent in patients with no PMC (odds ratio = 1.8). Logistic regression showed that the presence, as well as the number, of PMCs were significant risk factors in the

prediction of survival after injury. After taking into account the effects of ISS, RTS and age, the risk of death increased by 2.25 in the presence of PMC (CI = 1.07-4.07, P= 0.032).

Consequently traumatologists must be aware that PMCs are common and can have a profound effect on the outcome of injured victims. It is therefore essential that an accurate medical history is obtained from these patients and management carried out.

C. Milroy, D. Warwick, M. Clancy (Bristol, UK) External

pelvic fixation in the South West

External pelvic fixation is recommended for the management of hypovolaemia in the presence of unstable pelvic fractures. Its success may depend on the immediate availability of experi- enced personnel and appropriate equipment.

To assess this availability a survey of 30 middle-grade trauma surgeons representing 12 hospitals in the South West was undertaken.

Ninety per cent of these surgeons understood the indications for the external pelvic fixator but only 70 per cent felt able to apply a frame without senior assistance. A further 23 per cent felt clear diagrams would be necessary. Of the 12 hospitals surveyed only one had an external fixator available in the Accident and Emergency (A&E) department. Only four had a dedicated pelvic fixator within the hospital. Five hospitals had no appropriate external pelvic fixator at all.

Although the majority of middle-grade trauma surgeons understand the indications for pelvic fixation, a significant proportion are not confident to apply currently available models. Furthermore, in the majority of hospitals appropriate equipment was not readily available. These results suggest there is consider- able scope for improvement.

A protocol and dedicated pelvic fixator with clear diagrams in each A&E department may enhance the early management of these life-threatening injuries.

D. A. Lloyd, H. Carty, D. A. Roe, M. Patterson (Liverpool, UK) The value of skull X-rays in head-injured children

Trauma guidelines recommend a skull X-ray (SXR) in most children with a head injury. As a result, a large number of patients attending Accident and Emergency (A&E) departments with a head injury receive an SXR. We believe that most of these are unnecessary and contribute little to management, as a skull fracture is a poor predictor of intracranial injury in children with blunt head injury and does not influence management decisions.

From February 1993 to January 1995 we prospectively documented all children admitted to Alder Hey Children’s Hospital with a head injury. During this period it was policy for all children with a skull fracture to have a computed tomography (CT) scan of the head. CT was also performed when indicated for neurological reasons. Patients with a skull fracture and/or neurological symptoms and signs were admitted.

During the study period 6011 children had a skull X-ray of which 162 (2.7 per cent) demonstrated a skull fracture. There were 849 children admitted with a head injury. A CT scan was obtained for 106 (62 per cent) of patients with a skull fracture and 15 were found to have a brain injury or an intracranial collection. Eleven of these 15 had a CT scan for neurological indications; the four positive CT scans in neurologically normal children were a minor haemorrhage in three and a possible infarction beneath a clinically depressed fracture in one. There were 56 children with a fracture who did not have a CT, the significant reason being initial failure by the A&E or surgical staff to recognize the skull X-ray in 34 (21 per cent of total fractures).

A total of 34 children without a fracture had a CT for neurological indications and seven of these showed a significant

Proceedings of the British Trauma Society 371

intracranial injury. In all, four patients died from their head injury, only one of whom had a skull fracture.

We conclude that the presence of a fracture on the skull X-ray is not a reliable indication of intracranial injury in children. A policy of admission on clinical grounds with selective CT where indicated would be safe and would avoid unnecessary skull X-rays.

H. R. Williams, P. A. Templeton, R. M. Smith (Leeds, UK) Documentation audit of trauma patients Trauma is the major cause of morbidity and mortality under the age of 35 years in the UK. Reports including the Royal College of Surgeons’ report of the Working Party on ‘The Management of Patients with Major Injuries’ and the UK ‘Multiple Trauma Outcome Study’, depend on accurate and complete docu- mentation. Inadequate records make assessment of severity of injury and quality of care almost impossible and are unacceptable medico-legally.

Before 1992 no hospital in Yorkshire routinely used trauma charts to document injuries. In 1992 trauma documentation was introduced into the Accident and Emergency department of the Leeds General Infirmary. To evaluate the problem we audited the standard of trauma documentation in the Yorkshire region prior to the introduction of trauma charts. We then audited the standard of documentation before and after the introduction of this documentation in the Leeds General Infirmary.

Using the Leeds University School of Public health database of major trauma victims in the Yorkshire region, case notes of 226 patients who had died as a result of major injuries (Injury Severity Score > 15) during the 12 month period I October 1988 to 30 September 1989 were obtained. Using a standard appraisal form, the case notes were inspected for completeness of documentation of respiratory, circulatory and neurological status.

The notes of a second group of 102 patients who died as a result of major injuries over the last year in the Leeds General Infirmary were studied. The group comprised both primary and tertiary referrals to the hospital. The notes included the use of the new trauma documentation and were inspected with regard to the same parameters and compared with the results obtained from the previous group.

The results from 1988-1989 showed that the standard of documentation was poor, only 39.4 per cent being complete. In 1992-1994 the standard of documentation had improved. Without the use of a trauma chart the documentation increased to 90 per cent, but with the use of the trauma chart in primary referrals the result improved to 97 per cent. Within the 1992-1994 set the poorest standard of documentation was within that group of patients who were tertiary referrals without the use of trauma charts. Only 56 per cent of notes were complete in their documentation of the parameters being assessed.

The standard of documentation in major trauma has improved. This has important implications concerning audit, research and medico-legal matters. We therefore recommend that: (1) trauma charts are used routinely for all primary and tertiary referrals of injured patients; (2) tertiary referral patients are reassessed fully after transfer and a new trauma chart is completed.

L. C. Luke, D. A. Ritchie, A. Jone, C. Walker, M. Hartley (Liverpool, UK) The Trauma Forum: how to win friends and conhue to influence people Although the case for better trauma care in the UK has been well described over the past decade and there have been a number of h’ h- fil t lg pro e m erventions such as the Advanced Trauma Life

Support course, the hlajor Trauma Outcome Study, the Trauma Centre experiment in Staffordshire and the development of a British paramedic service, there has been relatively little pub- lished on the lower profile but often effective local responses to injuries in the UK. In this article, we describe the evolution of the Trauma Forum, a multidisciplinary monthly meeting at the Royal Liverpool University Hospital, which was established in 1993 and has been widely acknowledged as a pivotal factor in the improvement of the hospital’s overall response to the victims of injuries. The audience has exceeded 1000 over 24 months, with an average consultant attendance of over 20 per meeting, and the number of disciplies involved has increased steadily until the present time. This is in contrast to many other similar institutions throughout the UK where trauma audits have failed due to apathy. We describe the gradual development and restructuring of the meeting in response to audience surveys and the current educational climate and examine our successes and failures and the many difficulties encountered in sustaining widespread interest in trauma audits.

M. Hobbs, R. Mayou, P. Warlock (Oxford, UK) A randomized controlled trial of psychological debriefing for victims of road frafic

accidents Psychiatric problems-are common and disabling after major or minor road traffic accidents (RTAs). One-fifth of victims develop an acute stress reaction, and one-quarter display significant psychiatric problems within the first year. Psychiatric problems may obstruct recovery from the physical injuries sustained.

Awareness of post-accident psychiatric morbidity has stim- ulated interest in preventative psychological interventions, especially routine psychological debriefing. Although widely advocated after many types of injuries, debriefing has not been shown to be effective in preventing post-injury sympto- matology. No randomized controlled trials have yet been published, and the few studies which include comparison groups have shown variable responses to debriefing.

This prospective study aimed at testing whether a single, clincially feasible debriefing intervention, based on widely accepted principles, could reduce post-traumatic psychopath- ology in the injured victims of RTAs.

Consecutive patients admitted to a trauma centre following injury in RTAs were allocated randomly to the intervention or the non-intervention control groups. Patients in the experimen- tal group were offered a single debriefing intervention which combined a review of the traumatic experience, encouragement of emotional expression, and the promotion of early cognitive processing. In addition advice was given, both verbally and in a leaflet, about common post-traumatic psychological reactions and the value of talking to others about the experience, and advising early return to normal road travel. Experimental and control groups were followed up at 4 months.

One hundred and fourteen subjects entered the study, 59 in the intervention group and 55 controls. The intervention group displayed higher mean Injury Severity Scores (ISS) and mean duration of hospital stay, but no significant difference was found between the two groups at entry to the study in levels of psychiatric symptoms. Significantly fewer of the intervention group responded to follow-up than did patients in the control group.

Serious methodological problems were encountered, not least because investigations, surgical interventions and rapid dis- charge from hospital made it difficult to interview some patients and necessitated an earlier psychological intervention in others than was clinically desirable, within 24 to 48 h in most cases.

At follow up, there was evidence of persisting psychiatric skmptoms in both experimental and control groups. There were